Family physician treats death and dying with honesty, dignity

June 06, 2007|DAVID RUMBACH Tribune Staff Writer

SOUTH BEND -- The hospice movement was in its infancy when David Tribble got chewed out for confirming a patient's hunch that she was dying of leukemia. Tribble was a second-year medical student at Temple University when the woman asked him point-blank about her true condition. He confirmed what her attending physician had decided to withhold from her: She had leukemia and her treatments were failing. The woman, a nurse anesthetist with a teenage son, "tattooed'' the attending physician the next time she saw him on rounds. That was followed in short order by another dressing down, of Tribble by his med school superiors. "I was asked 'Give us one good reason we should not kick you out of medical school,' " said Tribble, medical director of the South Bend-based Center for Hospice and Palliative Care. Hospice milestones The year that Tribble got in trouble at Temple, 1974, was also the year that the first hospice program opened in the United States. Dame Cicely Saunders, who had launched the hospice movement in suburban London in 1967, established the first American program that year in New Haven, Conn. In the ensuing three decades, the hospice philosophy of advocating a patient's right to die with dignity has been widely accepted, and the brand of paternalism that allowed physicians to unilaterally decide what's best for terminal patients has gone by the wayside. More recently, hospice, and palliative care itself, has been recognized as a unique branch of medicine. The formal seal of approval for the technical side of hospice came last fall when it was accepted as a subspecialty by the American Board of Medical Specialties, American medicine's final authority on such matters. What began as a stark challenge to the medical profession's attitude toward death and the dying has been embraced by 11 specialties -- including internal medicine, obstetrics, emergency medicine and anesthesiology -- that will offer training and certification in hospice care and pain management. For Tribble, the run-in with the attending physician was a "formative experience'' that shaped his view of medical practice. In retrospect, he concedes that he overstepped his bounds as a student. But he also believes that the woman deserved honesty and that her attending doctor was acting unethically. Tribble has served as a part-time assistant director for the nonprofit Center for Hospice and Palliative Care since 1992 while also practicing family medicine in South Bend. Two years ago, he left his family practice altogether to become the agency's full-time medical director. His motivations were "not all noble,'' he said. The job's regular hours allow him both to "live more like a human and do something I love." "It was a combination that was impossible to resist,'' he said. Tribble is one of only 32 doctors in Indiana to be board-certified in hospice/palliative care and the only one in north central Indiana. (His certification, by the American Board of Hospice and Palliative Care, predates the newer ABMS certificate.) Doctors with this credential have demonstrated expertise both in care for the dying and in pain management for patients in general. Different goals Comfort, not cure, is the goal of hospice medicine, a fact which shapes medical decisions in interesting ways. At the least, Tribble said, it spares patients from harsh treatments that have little chance of prolonging life. Those include, in his view, many procedures commonly performed in hospital intensive care units. "I have seen some horrible things done to people in the name of keeping them alive,'' Tribble said. Doctors are not solely to blame, Tribble said. Often, it's the patients themselves and their families who demand heroic-but-futile treatments at the end of life. Family members may view a decision to use hospice care as abandoning their loved one to disease. Tribble said some doctors feel that way, going so far as to belittle hospice care as "standing around and watching you die.'' But good hospice doctors are anything but idle, according to Dr. David Bennahum, a retired professor of internal medicine and geriatrics at the University of New Mexico. Their expertise in the physiological stages of death enable them to anticipate symptoms, he said. And their training and expertise in palliation allow them to treat symptoms more effectively. "Treating pain requires technical knowledge,'' he said. Shortness of breath is an example of a common symptom of the dying that's deceptively tricky, Tribble said. The intuitive thing to do for someone in breathing distress is to put an oxygen mask on their face. But many times people in "air hunger" actually have a normal amount of oxygen in their blood stream. Their distress may be caused by anxiety, a false neurological signal or a feeling of claustrophobia. "Why else would you see people grab at oxygen masks and try to get them off," he said. A more effective source of relief may be morphine, or simply clearing the room a bit if it's crowded and bringing in some cool air. Contrary to common belief, there are no treatments that are strictly forbidden in hospice care, Tribble said. "There's no such list," he said. "We're not here to deal death but to help patients make the best of the time left on this planet." Back to the Florida Keys Sometimes curative and palliative modes of treatment converge, as they did for a patient of Tribble's who was dying of cancer. The man wanted to go scuba diving one more time in the Florida Keys. But a tumor on his shoulder made it impossible for him to put on the gear. He was given radiation to shrink the tumor, not to beat cancer but to enable him to dive. The treatment worked. Tribble later received a phone call from the Keys; a worried dive master was fretting that the man would die in the water. "I told him, 'He doesn't care if he dies. He wants to do this,' " Tribble said. "They helped him into the water, and he was down there with his wife for about 20 minutes." The man survived the dive and died a few days later. Tribble said hospice physicians also recognize that the pain people feel at the end of life usually has an important spiritual element, one that's beyond the reach of medications. Issues such as fear of abandonment, unresolved family problems and crises of faith make a person's pain immeasurably worse. Physicians must be attuned to spiritual suffering and help address it, not personally but as part of a team that includes social workers and counselors. "It's very difficult to deal with pain when you haven't dealt with suffering,'' Tribble said. "That's part of my job as well, and I have to be comfortable with that idea." Staff writer David Rumbach: drumbach@sbtinfo.com (574) 235-6358